Provider Demographics
NPI:1326802075
Name:ROJAS ULLOA, GRETHA
Entity Type:Individual
Prefix:
First Name:GRETHA
Middle Name:
Last Name:ROJAS ULLOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 COLONIAL WAY APT B
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5315
Mailing Address - Country:US
Mailing Address - Phone:786-326-5711
Mailing Address - Fax:
Practice Address - Street 1:489 LANTERN WOOD DR
Practice Address - Street 2:
Practice Address - City:SCOTTDALE
Practice Address - State:GA
Practice Address - Zip Code:30079-6800
Practice Address - Country:US
Practice Address - Phone:786-326-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-213696106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician